Tuesday, November 18, 2008

Taking two of the many who have expressed outrage over this issue, Longrider and Tim Worstall think the question of presumed consent to organ donation is a question of principle: whether or not we own our own bodies.

Dissenting opinion is rare on the Liberal and Libertarian front and more pragmatic. A system of presumed consent would save lives and might actually be a better reflection of the majority of the wishes of people whose organs are up for grabs, as it were, but who have not got around to expressing a clear intention to donate (up to 90% of people surveyed say they would like to donate their organs, far fewer sign a consent before they die).

Tim goes further:

Accept that people do own their own bodies and allow them to sell them. This is the system in Iran and no, it isn’t a coincidence that Iran is the only country in the world without a shortage of kidneys for transplant.

Mehrdad lost his job on the railways and now faces mounting debts. He wants to sell a kidney to fund a new job as a taxi driver.

But if the poor are overwhelmingly sellers of kidneys, at least one study of recipients of kidneys suggest that the great majority of those receiving kidneys were also poor:

The majority (73%) did not have a high school diploma, 15% were illiterate, 85% were below the poverty line, 52% were from rural areas...

And here's the critical point:

... 98% were covered by insurance

Poor people, many illiterate, most rural, had made private provision for their health care. The BBC's piece seems to have been unable to find space for this piece of information, suggesting instead that if you couldn't find the money, you couldn't get a kidney. True enough, but the implication is that few poor people benefit from transplants, and that seems to be the opposite of the truth, to put it delicately.

Mind you, the same study also suggests that they needed renal treatment in the first place because of the indirect effects of poverty:

We conclude that patients with CKD in our study had acquired this condition possibly due to negligence and lack of basic health care in the lower socioeconomic class.

Replacing the word "say" with "do" seems an equally good rule of thumb when it comes to the application of principles to the world we actually live in. However strongly we might hold a principle, it should be broken in any given case if, in that given case, the result would be "outright barbarous".

It's interesting to apply this rule to arguments like this one. Especially with issues of health, it can cut through a morass of debate like a razor. Should people be allowed to pay for drugs privately while receiving treatment for diseases like cancer and Altzheimer's? To refuse this would be to condemn people to unnecessary death while improving the condition of absolutely nobody at all: outright barbarous.

If there's a conflict between property and life, property should normally take second place. If, for example, I were driving a hired car and saw another car out of control, heading for a group of pedestrians, would I be wrong to place the hire car - not my property - in the way and so save lives? No, the consequence would be to value a replaceable car above irreplaceable lives. It would be avoidable broken limbs and torn bodies: outright barbarous.

But take that to its extreme and we'd have a situation in which nobody were entitled to refuse to donate their organs. This would cause significant upset to people who worry about wandering an afterlife with bits of their immortal bodies missing. Or something. I'm at a bit of a loss to understand what the objection might be.

Nevertheless, people are entitled to do even deeply strange things to their property - as a visit to any DIY store will confirm. It's their property. It's up to them.

So, should there be a market in kidneys in the UK, as there is in Iran? Should poor people, as well as the less poor, be able to make private provision for their healthcare and thereby obtain prompt transplants when needed?

The alternative would be people living through the pain, dialysis and debility endured by my brother in law at the moment, quite unnecessarily, while others are unable to go into business as taxi drivers. The latter isn't as frivolous at it might sound, as anyone who has stood helplessly, gazing up at the bottom rung of the ladder could testify. All these outcomes of our present arrangements - unnecessary debility, avoidable death, an inability to make decisions and trade-offs for oneself in order to get a start or a restart in life - are outright barbarous.

Should the state claim sovereignty over our bodies? Of course not - as any Republican will tell you, that is outright barbarous.

But what of the actual proposals we see today? These are simply a matter of presumption. If anyone has made it clear what they wish for themselves, then these wishes will be observed. What if they haven't?

At the moment, we presume we cannot presume. It isn't really true to suggest that this proposal just exchanges one presumption for another. It seeks to swap an absence of presumption for a presumption.

But what of the consequences of the proposed change - given that people would retain an absolute right to express a view about what should happen to their remains and that any such views that have been expressed will be honoured.

What happens today is that even though most people say they want their organs to be used to help others, most people get buried intact and others die for want of donor organs.

To refuse to exchange that for a situation in which, quite realistically (especially if a market is also allowed) NOBODY would die for want of a donor organ, and some dead bodies will be buried or cremated with bits missing even though a minority of their previous occupants would have preferred that not to have been the case, though not so much they actually bothered to do anything about it...

To refuse to exchange dead and dying men, women and children for a country in which those lives are saved, while the wishes of everybody who expressed a view about the disposal of their remains are respected...

8 comments:

It's worth noting that the Iranian system isn't really all that private a market. It's Govt funded. As I assume any one anywhere else would be. About a year's average income is the price on offer to those who donate. So around £25 k or so here....which is less, I believe, than the cost to the NHS of a year of dialysis.There may well be a private market on top of that, don't know.But I'm not advocating a "free market" in kidneys, rather, the adoption of some market practices into this, as you note above, rather fraught situation. Not so much for moral reasons as for pragmatic ones, more lives will be saved.

I'm sure it's driven in part by my revulsion at the idea that the State lays claim to oqwnership of our bodies though.

I think one of the many concerns regarding the proposed 'opt out' rather than 'opt in' vision of organ donation, is that many people fear how they will be treated in hospital,(in fact if in the case of someone with 'expensive' multiple life threatening injuries, whether they will be treated at all) and at what point would the medical profession no longer see you as a patient worth saving but as GPO - good for parts only.

All we need is a law that says that anyone who lives off, or has lived off, the BBC TV Licence Fee will be cut up to provide parts for the rest of us. On demand. Without a postcode lottery. Starting with Greg Dyke. And the oily chap with the cigar.

The real reason that people keep dying for lack of life-saving transplants, after 11 years of Labour spending on the NHS, is not that there aren’t enough donors. There are plenty of donors – 14m have signed up. Their organs just aren’t used. As Tim Statham, chief executive of the National Kidney Federation, explained last week, about 1,500 people die in the UK every day and 400 of them, statistically speaking, have signed the organ donor register. That makes about 800 available kidneys a day, not to mention all their other organs. Wasted. Denied to the living and buried or burnt. The real problem, as Brown and his people ought to have known, is that there isn’t enough surgery to make use of all these organs.

This being true then we will, at best, save only a handful of extra lives and perhaps none at all.

Bugger the lives saved. I work in email marketing and you ain't allowed to presume consent to send an email to someone. Why should the state assign itself the right to presume my consent to harvest my organs? There are always 'lives to be saved' that justify every increase in the state's power. The promised safeguards and opt-outs always disappear or come with an 'admin charge'. How long before the wretched system is EU-wide, before the organs are 'donated' to Iranian's as humanitarian aid, how long before they are sold to medical research firms and harvesting becomes farming?

Tired and Emotional's comment may sound callous, but it is essentially right. The argument in favour of presumed consent is based on an assumption that the majority are too lazy to make their feelings known. The only evidence for this is a series of polls that suggest the majority are in favour yet do nothing about it.

This is a flawed assumption. people lie to pollsters and given the nature of this subject, are under pressure to say yes when they mean no as it will appear callous. And, frankly, a poll of 2,000 people from a population of 60m is hardly representative.

One final point - sure people may be able to opt out, but how will this be recorded? On a database, no doubt as these are so beloved of our benevolent leaders. Why, exactly, should people have to make their views known to the state when it is none of the state's business? Frankly, the state becoming involved in what is a deeply personal matter is outright barbarous.

I say this as someone who believes that donation is a good thing that should be encouraged. but that is it; encouraged, not assumed.

Bugger the lives saved. I work in email marketing and you ain't allowed to presume consent to send an email to someone. Why should the state assign itself the right to presume my consent to harvest my organs?

The reason it can and should do so is because once you die, you shift from personhood to property. Now, unless you have created a contract beforehand, such considerations as to what do with your body should be left to the market.